Healthcare Provider Details

I. General information

NPI: 1437538725
Provider Name (Legal Business Name): BRIAN H. GRAHAM MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6455 LA JOLLA BLVD #315
LA JOLLA CA
92037-6627
US

IV. Provider business mailing address

6455 LA JOLLA BLVD #315
LA JOLLA CA
92037-6627
US

V. Phone/Fax

Practice location:
  • Phone: 619-665-2159
  • Fax: 858-836-1159
Mailing address:
  • Phone: 619-665-2159
  • Fax: 858-836-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN H GRAHAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-665-2159